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HY-VEE PHARMACY FULFILLMENT CENTER 4016
CAH161367-00 PELLA REGIONAL HEALTH CENTER
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Covered Entity Details
Entity Name
PELLA REGIONAL HEALTH CENTER
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH161367-00
Entity Address
404 JEFFERSON ST.
PELLA, IA 50219
Medicare Provider Number
161367
Participating Start Date
1/1/2011
Last Recertification Date
8/20/2024
Pharmacy Details
Pharmacy Name
HY-VEE PHARMACY FULFILLMENT CENTER 4016
Pharmacy Address
HY-VEE INC
4707 FLUER DR
DES MOINES, IA 50321
Pharmacy Comments
11-22-2013 Address correction
Contract Details
Approval Date
11/22/2013
Contract Begin Date
1/1/2014
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
12/15/2023
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
Ronald Wauters, Chief Financial Officer
(641) 628-6603 Ext: 6603
Contract Pharmacy Representative
Hy- Vee
BOB EGELAND, VP PHARMACY OPERATIONS
(515) 267-2800
Signed By Date
11/22/2013
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